Every finding on record at Waynesboro Post Acute & Rehabilitation

Based on facility policy review, medical record review, and interview, the facility failed to provide written information on how to formulate an Advance Directive for 13 of 24 (Residents #2, #7, #9, #10, #12, #19, #30, #35, #36, #42, #46, #48, and #55) sampled residents. The findings include: 1. Review of the facility policy titled, Advanced Directives, dated [DATE], revealed .Advance directives will be respected in accordance with state law and facility policy.Advance Directive . written instruction, such as a living will or durable power of attorney for health care, recognized under State law.relating to the provision of health care when the individual is incapacitated.Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. In addition, facility staff should verify the resident's wishes with regard to cardiopulmonary resuscitation (CPR).Written information will include a description of the facility's policies to implement advance directives and applicable state law.Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record.The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. 2. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Diabetes, Morbid Obesity, and Respiratory Failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 scored a 10 on the Brief Interview for Mental Status (BIMS) assessment, which indicated he was moderately cognitively impaired. Review of the Acknowledgement of Resident Information on Advance Directives form revealed the form was not provided, completed, and signed by the Resident and/or RP until [DATE] when the surveyor inquired about Resident #2's Advance Directive. 3. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE], with diagnoses including Dementia, Hypertensive Heart Disease with Heart Failure, and Pruritus. Review of the quarterly MDS assessment dated [DATE], revealed a score of 12 on the BIMS assessment, which indicated she was moderately cognitive impaired. The facility was unable to provide documentation that the resident and/or Responsible Part (RP) were provided written documentation to formulate an advance directive. 4. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE], with diagnoses including Diabetes Mellitus, Dementia, and Atrial Fibrillation. Review of the quarterly MDS assessment dated [DATE], revealed Resident #9 scored a 99 on the BIMS assessment, which indicated he was severely cognitively impaired. Review of the Acknowledgement of Resident Information on Advance Directives form revealed the form was completed, signed, and provided to the Resident and/or RP until [DATE] when the surveyor inquired about Resident #9's Advance Directive. 5. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE], with diagnoses including Anxiety, Muscle Weakness, Rheumatoid Arthritis, and Macular Degeneration. Review of the significant change MDS assessment dated [DATE], revealed resident #10 scored a 15 on the BIMS assessment, which indicated she was cognitively intact. The facility was unable to provide documentation that the resident and/or RP were provided written documentation to formulate an advance directive. 6. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including Dementia, Diabetes, Anxiety, Bipolar Disease, Depression, and Hypertension. Review of the quarterly MDS assessment dated [DATE], revealed Resident #12 scored a 15 on the BIMS assessment, which indicated she was cognitively intact. The facility was unable to provide documentation that the resident and/or RP were provided written documentation to formulate an advance directive. 7. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE], with diagnoses including Dementia, Hypertension, Depression, and Gastro-Esophageal Reflux. Review of the significant change MDS assessment dated [DATE], revealed no BIMS assessment had been completed and the resident had severely impaired cognitive skills for daily decision making. The facility was unable to provide documentation that the resident and/or RP were provided written documentation to formulate an advance directive. 8. Review of the medical record revealed Resident #30 was admitted to the facility on [DATE], with diagnoses including Dementia, Psychotic Disorder with Delusions, and Mood Disorder. Review of the quarterly MDS assessment dated [DATE], revealed Resident #30 scored a 99 on the BIMS assessment, which indicated she was severely cognitively impaired. The facility was unable to provide documentation that the resident and/or RP were provided written documentation to formulate an advance directive. 9. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE], with diagnoses including Diabetes, Lack of Coordination, and Guillain-Barre Syndrome (a condition in which the body's immune system attacks the nerves). Review of the quarterly MDS dated [DATE], revealed Resident #35 scored a 15 on the BIMS assessment, which indicated she was cognitively intact. Review of the Acknowledgement of Resident Information on Advance Directives form revealed the form was provided, completed, and signed by the Resident and/or RP until [DATE]. 10. Review of the medical record revealed Resident #36 was admitted to the facility on [DATE], with diagnoses including Diabetes Mellitus, Guillan-Barre Syndrome, Chronic Obstructive Pulmonary Disease, Tobacco Use, Depression, and Anxiety. Review of the annual MDS assessment dated [DATE], revealed Resident #36 scored a 14 on the BIMS assessment, which indicated she was cognitively intact. The facility was unable to provide documentation that the resident and/or RP were provided written documentation to formulate an advance directive. 11. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Heart Failure, Anxiety, Depression, and Alcohol, Dependence with Alcohol-Induced Persisting Dementia. Review of the quarterly MDS assessment dated [DATE], revealed Resident #42 scored a 6 on the BIMS assessment, which indicated he had severely impaired cognition. The facility was unable to provide documentation that the resident and/or RP were provided written documentation to formulate an advance directive. 12. Review of the medical record revealed Resident #46 was admitted to the facility on [DATE], with diagnoses including Chronic Atrial Fibrillation, Diabetes Mellitus, and Hypertensive Heart Disease with Heart Failure. Review of the quarterly MDS assessment dated [DATE], revealed Resident #46 scored a 10 on the BIMS assessment, which indicated she was moderately cognitively impaired. Review of the Acknowledgement of Resident Information on Advance Directives form revealed the form was provided, completed, and signed by the Resident and/or RP until [DATE]. 13. Review of the medical record revealed Resident #48 was readmitted to the facility on [DATE], with diagnoses including Osteomyelitis, Acquired Absence of Left Leg Below the Knee, and Hypertensive Heart Disease without Heart Failure. Review of the quarterly MDS assessment dated [DATE], revealed Resident #48 scored a 13 on the BIMS assessment, which indicated he was cognitively intact. The facility was unable to provide documentation that the resident and/or RP were provided written documentation to formulate an advance directive. 14. Review of the medical record revealed Resident #55 was admitted to the facility on [DATE], with diagnoses including Morbid Obesity, Anxiety Disorder, and Diabetes Mellitus. Review of the quarterly MDS assessment dated [DATE], revealed Resident #55 scored a 14 on the BIMS assessment, which indicated she was cognitively intact. Review of the Acknowledgement of Resident Information on Advance Directives form revealed the form was provided, completed, and signed by the Resident and/or RP until [DATE]. During an interview on [DATE] at 4:39 PM, the Social Service Director (SSD) was asked if advanced directives should be completed on admission. The SSD stated, Yes. The SSD was asked if advance directives should be in the residents' medical record. The SSD stated, It should. The SSD was asked why some advance directives were signed and dated [DATE]. The SSD stated, We had just started putting those in the admission packet. The SSD was asked if the advance directives dated [DATE] were completed after the surveyor's request for the forms. The SSD stated, Yes. The SSD was asked what was being done to assess advance directive prior to putting them in the admission packet. The SSD stated, We were just doing the post form.

Based on facility policy review, medical record review, observation, and interview, the facility failed to follow physician orders for the use of oxygen administration for 1 of 1 (Resident #36) residents reviewed for respiratory care. The findings include: 1. Review of the facility policy Oxygen Administration, dated 1/5/2025, revealed .The purpose of this procedure is to provide guidelines for safe oxygen administration.Verify that there is a physician's order for this procedure .Review the physician's orders.After completing the oxygen setup or adjustment, the following information should be recorded.The rate of oxygen flow. 2. Review of the medical record revealed Resident #36 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Guillan-Barre Syndrome (a condition in which the body's immune system attacks the nerves), and Anxiety. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #36 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was cognitively intact. Review of the Care Plan dated 6/19/2026, revealed .has a dx [diagnosis] of COPD. She is at risk for respiratory complications secondary to COPD related to smoking.administer oxygen as ordered. Review of Physician's Order dated 6/29/2026, revealed Oxygen 2 liters via [by way of] nasal cannula continuous while in bed. Observation in the dining room on 6/28/2026 at 10:12 AM, revealed Resident #36 receiving oxygen at 4 l/min [Liters per minute] by BNC [Binasal Cannula- a tubing used to deliver oxygen through the nose]. Observation in Resident #36's room on 6/29/2026 at 8:39 AM, revealed Resident #36 receiving oxygen at 4 l/m via BNC. The facility failed to ensure Resident #36 received oxygen as ordered by the physician for 2 l/m via BNC. During an observation and interview in the resident's room on 6/29/2026 at 10:36 AM, LPN E verified that Resident #36's oxygen was set on 4 l/min BNC. LPN E was asked if she could show me the order. LPN E stated, Yes. The Standing orders were reviewed with LPN E that showed and verified that Resident #36 should have received oxygen at 2l/min BNC. During an interview on 6/29/2026 at 10:38 AM, Licensed Practical Nurse (LPN) E was asked what the Physician's Order for Resident #36's oxygen was. LPN E stated, .2 Liters.

Based on the facility's In Time/Out Time report and interviews the facility failed to ensure there was Registered Nurse (RN) coverage for 8 consecutive hours a day, 7 days a week for 3 of the 28 days reviewed. The facility's census was 62. The findings include: Review of the employee In Time/Out Time report dated 5/30/2026 through 6/26/2026, revealed there was no RN on duty for 8 consecutive hours on the following dates: a. 5/31/2026 - 1.5 hours RN coverage b. 6/13/2026 - 7.0 hours RN coverage c. 6/14/2026 - 7.0 hours RN coverage The facility was unable to provide additional times sheets for the above dates requested. During an interview on 6/30/2026 at 2:22 PM, the DON (Director of Nursing) confirmed that there should be an RN on duty 8 consecutive hours, 7 days a week. The DON was asked if the lack of RN coverage in the facility could potentially put the residents at risk. The DON stated, Yes, but our LPN's (Licensed Practical Nurse) have IV (intravenous) certification.

Based on the facility policy review, Administrator's email review, medical record review, and interview, the facility failed to maintain access and availability to resident's medical records for 5 of 5 (Resident #55, #74, #75, #76, and #77) sampled residents reviewed for medical records prior to 6/18/2024. The findings include: 1.Review of the facility policy titled, Retention of Medical Records, dated 10/1/2021, revealed .Medical records shall be retained by the facility in accordance with current applicable federal and state laws.Medical records of discharged residents will be retained for period required by State law.Seven years from the date of discharge when there is no requirement in State law. Review of the undated facility policy titled, Resident Rights, revealed .The Facility shall protect and promote the rights of each Resident, including each of the following rights.The Resident or Legal Representative has the right, upon oral or written request, to access all records pertaining to himself or herself, including clinical records. 2. Review of the Administrator's email dated 6/29/2026 at 4:20 PM, revealed the Administrator wrote an email. The email stated, .I am reaching out regarding my access being suspended. Review of the [named Electronic Health Record (EHR) company] reply email dated 6/29/2026 at 7:31 PM, revealed a contact with the EHR company wrote an email. The email stated, .Based on your email I assume you're with [named facility]. They are a facility under [named organization] in our system. The [named account] has been disabled because they haven't paid fees associated with their.archive . Review of the Administrator's email dated 6/29/2026 at 7:46 PM, revealed the Administrator wrote an email to a [named document managing company]. The email stated, .We have State surveyors in our building requesting records for a time period that we do not have access to due to our Change of Ownership. Is there any way to grant access tomorrow for 24 hours to allow us to pull what State surveyors are requesting. 3. Review of the medical record revealed Resident #55 was readmitted to the facility on [DATE], with diagnoses including Bullous Pemphigoid, Anxiety, Diabetes Mellitus, and Morbid Obesity. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #55 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was cognitively intact. The facility was unable to access or provide all medical records for Resident #55 prior to 6/18/2024. 4. Review of the medical record revealed Resident #74 was admitted to the facility on [DATE], with diagnoses including Hypertension, Alzheimer's Disease, Anxiety, and Depression. Review of the significant change MDS assessment dated [DATE], revealed Resident #74 scored a 3 on the BIMS assessment, which indicated she was severely cognitively impaired. The facility was unable to access or provide medical records for Resident #74 prior to 6/18/2024. 5. Review of the medical record revealed Resident #75 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Wedge Compression Fracture of Thoracic Vertebra (a break in the front part of the spine), Depression, Anxiety, and Diabetes Mellitus. Review of the admission MDS assessment dated [DATE], revealed Resident #75 was unable to complete the BIMS assessment, and was moderately cognitively impaired. The facility was unable to access or provide medical records for Resident #75 prior to 6/18/2024. 6. Review of the medical record revealed Resident #76 was admitted to the facility on [DATE], with diagnoses including Anemia, Hypertension, and Dementia. Review of the quarterly MDS assessment dated [DATE], revealed Resident #76 scored a 3 on the BIMS assessment, which indicated he was severely cognitively impaired. The facility was unable to access or provide medical records for Resident #76 prior to 6/18/2024. 7. Review of the medical record revealed Resident #77 was admitted to the facility on [DATE], with diagnoses including Hypertension, Alzheimer's Disease, Parkinson's Disease, Anxiety, and Depression. Review of the quarterly MDS assessment dated [DATE], revealed Resident #77 scored 00 on the BIMS assessment, which indicated she was severely cognitively impaired. The facility was unable to provide medical records for Resident #77 prior to 6/18/2024. During an interview on 6/30/2026 at 7:36 AM, the Administrator stated the facility reached out to the company that has the medical records and access was denied due to an outstanding balance of $3000.00 that is owed by the previous owners. Therefore, the facility won't be getting access to the medical records as previously requested. During an interview on 6/30/2026 at 8:33 AM, the Administrator was asked who had the access of the resident's medical records. The Administrator stated, [named previous owner] cut us off when we separated from them on 6/18/2024.A data retrieval was completed by them [the former owners] from the previous EHR [Electronic Health Record].and dumped into [named EHR].Access to [named EHR] was read only. The Administrator was asked if the access to the resident records on the EHR were a defined period of time. The Administrator stated, They never told me. I would check to see if I had access periodically. The last time I checked was 6/28/2026, when you guys showed up and we no longer had access.Email correspondence with the [named EHR] told me [named previous owners] had an outstanding balance.and access was denied because of the [named previous owners] debt. The Administrator was asked if there was any correspondence with the previous owners. The Administrator stated, Not this time, we attempted that October 2025, with the complaint survey with no resolution. During an interview on 6/30/2026 at 5:18 PM, the Administrator was asked how long medical records should be kept. The Administrator stated, 10 years for residents. The Administrator was asked per regulations should those records be available. The Administrator stated, They should be available.

Based on facility policy review, Plan of Correction (POC) review, and interview, the facility failed to monitor the availability of medical records to residents' medical records for 5 of 5 (Resident #55, #74, #75, #76, and #77) sampled residents reviewed for medical records prior to 6/18/2024, per the facility's POC, and failed to ensure ongoing compliance following the abbreviated survey conducted by the State Survey Agency (SSA) on 10/13/2025 through 10/15/2025, and the revisit conducted on 11/24/2025. The findings include: 1. Review of the undated facility policy titled, Quality Assurance Performance Improvement (QAPI) Committee, revealed .The facility will maintain systems and processes to ensure that the quality assurance/performance improvement program identifies and address issues and/or risks and that implements corrective action plans as necessary. All appropriate and reasonable efforts will be made and resources provided to maintain compliance with applicable regulations for nursing facilities, and needs of residents.The facility will maintain documentation and demonstrate evidence of its ongoing QAPI program.This may include, but is not limited to systems and reports demonstrating systemic identification, reporting, investigation, analysis, and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities.Action plans, corrective and preventive, will be developed and monitored for quality improvement based on identified opportunity. After implementing those actions, the facility will monitor and measure the success, and track performance to ensure that improvements are realized and sustained.The facility will follow any state specified guidance regarding QAPI.The QAPI program is sustained during transitions in leadership and staffing. Review of the undated facility policy titled, Resident Rights, revealed .The Facility shall protect and promote the rights of each Resident, including each of the following rights.The Resident or Legal Representative has the right, upon oral or written request, to access all records pertaining to himself or herself, including clinical records. Review of the facility policy titled, Retention of Medical Records, dated 10/1/2021, revealed .Medical records shall be retained by the facility in accordance with current applicable federal and state laws.Medical records of discharged residents will be retained for period required by State law.Seven years from the date of discharge when there is no requirement in State law. Review of the facility policy titled, Administrator, dated 1/5/2025, revealed .The Administrator is responsible for, but not limited to.Evaluating and implementing recommendations from the facility's committees (i.e. [in other words], Quality Assessment and Assurance . 2. Review of the Facility's POC dated 11/17/2025, from the abbreviated survey that occurred on 10/13/2025-10/15/2025, revealed .Corrective Action for Resident(s) Affected.Access to all medical records previously stored in the prior ownership EMR [electronic medical record] system was restored to current ownership via [by way of] collaboration with prior ownership on November 11, 2025.Identification of Other Residents Potentially Affected.All current residents' medical records were reviewed to ensure accessibility by the Administrator on November 11, 2025.Systemic Changes to Prevent Recurrence.All staff were educated on the facility Resident Rights Policy which includes resident rights to their medical records. Education will be provided by the Director of Nursing, Administrator, or Assistant Director of Nursing by November 16, 2025. Any staff who are not educated by the completion date will be prior to their next shift worked.QAPI held 11/11/2025 and facility implemented a Retention of Medical Record policy ensuring compliance.Monitoring/QA [quality assurance] Process. The Medical Records Director or Director of Nursing will audit 10 resident records monthly ongoing to verify accessibility of resident records. Results will be reviewed through QAPI monthly. The QAPI committee may adjust audits and interventions to ensure compliance is maintained.Completion Date.November 17, 2025. 3. During an interview on 6/30/2026 at 8:33 AM, the Administrator was asked to describe the situation that resulted in past medical records not being available for numerous residents. The Administrator stated, .name of the previous owner was [Named previous owner]. When we separated from them 6/18/2024 they cut us off on the 17th or 18th at midnight of June 2024. No data dump was completed by them, from [Named electronic health record [EHR] previously used by the facility] into [Named EHR currently used by the facility] .[Named EHR previously used by the facility] no longer exists as well, they data dumped into [Named data storage company]. Access to [Named data storage company] access was read only. The Administrator was asked if the access was for a defined period. The Administrator stated, They never told me, I would check to see if I had access periodically.The last time I checked was Sunday when you guys showed up, we no longer have access. The Administrator was asked if he had any contact with [Named Data Storage Company]. The Administrator stated, Email correspondence with [Named data storage company], they told me [Named Previous Owner] has an outstanding balance, they have tried to communicate with them with no correspondence. Request for access or 24-hour access was denied because it was [Named Previous Owner] debt. The Administrator was asked if he had any correspondence with [Named Previous Owner] attempting to get the records or the bills paid. The Administrator stated, Not this time, we attempted that October 2025 with the complaint survey with no resolution. The Administrator was asked if during the period that they had access to the medical records, could they have downloaded the records or stored them. The Administrator stated, No it was read only, I could only view it. During an interview on 6/30/2026 at 5:18 PM, the Administrator was asked how long medical records should be kept. The Administrator sated, 10 years for residents. The Administrator was asked if he felt the facility was still in compliance with the POC from 2025 regarding having access to the residents' medical records. The Administrator stated, I want to say yes, we have what we have for them. We may even have more than we thought we did. The Administrator was asked if he remembered what the POC was regarding not having the medical records. The Administrator stated, I do not. The Administrator was asked if by regulation should residents' medical records be available. The Administrator stated, They should be available. Refer to F842

Based on facility policy review, review of the Centers for Disease Control and Prevention (CDC) guidelines, observation, and interview, the facility failed to establish and implement an effective infection control program to identify, report, investigate, and control infections and communicable diseases when the facility failed to track and monitor organisms for outbreaks and cross contamination. This had the potential to affect 62 of 62 residents who resided in the facility and when the facility failed to ensure proper infection control practices were followed during medication administration when 2 of 2 nurses (Licensed Practical Nurse (LPN) A and Registered Nurse (RN) C) failed to wear a gown when administering Medication through a PEG (percutaneous endoscopic gastrostomy) tube (a plastic tube placed in the stomach to administer food, water and/or medications) for a resident on Enhanced Barrier Precautions (EBP) and failed to perform hand hygiene between residents when administering oral medications. The findings include: 1. Review of the undated facility policy titled, Surveillance for Infections, revealed .The Infection Preventionist [designee] will conduct ongoing surveillance for healthcare-associated-infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions.The purpose of the surveillance of infections is to identify both individual case and trends of epidemiologically significant organisms and healthcare-associated Infections, to guide appropriate interventions, and to prevent future infections.For residents with infections that meet the criteria for definition of infection for surveillance, collect the following data.resident's name.room number.unit.date of onset of infection.Infection site.Pathogens. Review of the facility policy titled, Hand Hygiene, revised 1/5/2025, revealed .The facility promotes hand hygiene as a simple and effective method for preventing the spread of infections. Glove use is not a substitute for hand hygiene. All staff are to preform hand hygiene during all care activities and while working in all locations within the facility.Hand hygiene: means to clean one's hands with either a sanitizer product or with soap and water.before and after direct contact with a resident's intact skin.after contact with inanimate objects.before and after removing gloves. Review of the facility policy titled, Enhanced Barrier Precautions (EBP) Policy, revised1/5/2025, revealed .The purpose of this policy is to outline the guidelines for implementing EBP in order to reduce the transmission of multidrug-resistant organisms (MDROs) within our facility. EBP will be utilized in conjunction with standard precautions to provide targeted gown use during high-contact resident care activities.This policy applies to all staff members involved in resident care within the facility.Criteria for implementing EBP.Residents with wound and/or indwelling medical devices.EBP should be utilized during the following activities: Device care or use. feeding tube. Review of the Infection Control Manual Volume 1, dated 10/2025, revealed .This Infection Prevention and Control program is designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections.The goal of the Infection Preventive and Control Program is to provide a system of preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for patients, partners, volunteers, visitors, and others who provide contracted services.There is ongoing surveillance among patients and partners to identify possible infection or communicable diseases; to report as required by state or federal law; to investigate and control spread.Infection Control Committee.The committee will evaluate the effectiveness of the Infection Control program through review, trending, and reporting the following.Outbreak tracking and trending. 2. Review of the Healthcare-Associated Infections Worksheet Sites and Pathogens, dated 3/2026, 4/2026, and 5/2026, revealed no documentation that infections were tracked by organism. Review of the Monthly Surveillance Summary Report, for March 2026, April 2026 and May 2026, revealed no documentation that infections were tracked by organism. The facility was unable to provide documentation of tracking and trending of infections by organism and location in the facility to monitor for outbreaks, cross contamination, and the need for staff education or reeducation related to Infection Control. During an interview on 6/30/2026 at 8:54 AM, the Infection Control Preventionist (ICP) was asked how do you know there is not a pathogen outbreak if you are not tracking and trending. The ICP responded, .I understand what you are saying. The ICP was asked should tracking and trending of all pathogens, cultures and antibiotics be tracked. The ICP responded, yes. 3. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE], with diagnoses including Dementia, Anxiety Disorder, Dysphagia, Oropharyngeal Phase. The quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #19 had a Brief Interview for Mental Status (BIMS) score of 99, which indicated Resident #19 was severely cognitively impaired. Review of the Physicians Order dated 2/3/2026, revealed .Reglan Oral Tablet (medication used for digestive problems) 5 MG [milligrams] (Metoclopramide HCl) Give 1 tablet via [route] PEG-Tube three times a day . Review of the Physicians Order dated 2/4/2026, revealed . traMADol [Tramadol] HCl (medication used for pain) Oral Tablet 50 MG Give 1 tablet via PEG-Tube every 8 hours . Review of the Physician Order dated 3/1/2026, .Infection Precautions - enhanced barrier for PEG tube care every shift . Observation outside Resident #19's room during medication administration on 6/29/2026 at 2:00 PM, revealed Licensed Practical Nurse (LPN) A sanitized her hands, gathered the following medications of Reglan and Tramdol, crushed and placed each medication in its own medication cup, gathered 2 glasses of water, and locked medication cart. LPN A knocked and entered the resident's room and explained to resident the medication process. LPN A placed a barrier on overbed table and then placed the medication cups and water on barrier. LPN A sanitized hands and put on clean gloves. LPN A uncovered the resident and checked for placement and residual through the PEG tube, flushed the peg tube with 20ml of water and proceeded to administer the medications each followed by 20ml (milliliters) of water. LPN A removed the syringe and reconnected the PEG tube to the pump and covered the resident back with the sheet. LPN A entered the bathroom, cleaned the syringe, and returned to the bedside and hung it on the pole. LPN A removed her gloves then washed her hands with soap and water at the sink and exited the room. LPN A failed to wear a gown during the administration of the peg tube medications for a resident on enhanced barrier precautions. During an interview on 6/29/2026 at 2:15 PM, LPN A was asked if she should have worn a gown when giving medications through a feeding tube for a resident on EBP. LPN A stated .I realized I had not put on a gown when I was almost finished .yes, a gown should have been put on from the start . During an interview on 6/30/2026 at 3:15 PM the Director of Nursing (DON) was asked if a resident is on EBP and a staff member is in direct contact with the resident should a gown be worn.the [NAME] stated .Yes, a gown should be worn for all residents on EBP when coming into contact with them . 4. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE], with diagnoses including Diabetes Mellitus, Alzheimer's Disease, and Dementia. The quarterly MDS assessment dated [DATE], revealed Resident #23 had a BIMS score of 99, which indicated Resident# 23 was severely cognitively impaired. Review of the Physician Order dated 2/3/2026, revealed . Miralax Oral [medication used for constipation] Packet 17 GM (Polyethylene Glycol 3350), Give 1 scoop .in the morning . Review of the Physician Order dated 2/3/2026, revealed . Thiamine HCl [vitamin supplement] Oral Tablet (Thiamine HCl), give 1 tablet by mouth in the morning . Review of the Physician Order dated 3/6/2026, revealed .Zyprexa [antipsychotic medication] Oral Tablet 5 MG (Olanzapine), give 1 tablet by mouth two times a day . Review of the Physician Order dated 3/15/2026, revealed . Icosapent Ethyl Oral [medication used for high cholesterol] Capsule 1 GM [gram] give 1 capsule by mouth two times daily . Review of the Physician Order dated 3/15/2026, revealed . buspirone HCl [medication used for anxiety] Oral Tablet 15 MG give 1 tablet by mouth three times a day . Review of the Physician Order dated 3/15/2026, revealed . Depakote [medication used for seizures] .Oral Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium), give 2 capsules by mouth three times a day . Review of the Physician Order dated 3/15/2026, revealed . Namenda [medication used for dementia] Oral Tablet 10 MG (Memantine HCl), give 1 tablet by mouth two times a day . Observation outside Resident #23's room during medication administration on 6/30/2026 at 8:05 AM, revealed Registered Nurse (RN) C gathered the following mediations of Miralax, Thiamine, Zyprexa, Icosapent Ethyl, Buspirone, Depakote, Namenda, and placed them in medication cup, poured a glass of water, then locked medication cart. RN C failed to sanitize hands prior to gathering medications. RN C knocked on resident' #23's door and greeted resident. She explained to resident what medications she had and handed medication cup and water to resident. RN C proceeded to raise the head of the bed further, and observed the resident take medication, then RN C excepted the empty medication cup and water cup from the resident and threw them into the garbage and exited the room. RN C began to gather medication for next Resident. RNC failed to sanitize hand after exiting residents #23's room and before gathering mediations for the next resident. During an interview on 6/30/2026 at 8:37 AM, RN C was asked if she should have sanitized her hands upon exiting resident #23's room. RN C stated .yes . Review of the medical record revealed Resident #49 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Dementia, and Depression. The quarterly MDS assessment dated [DATE], revealed Resident #49 had a BIMS score of 99, which indicated Resident #49 was severely cognitively impaired. Review of the Physician Order dated 9/4/2025, revealed . Aspirin [medications used to thin the blood] 81 Oral Tablet Delayed Release (Aspirin), Give 1 tablet by mouth in the morning . Review of Physician Order dated 2/3/2026, revealed . Senna Plus [stool softner] Oral Tablet 8.6-50 MG (Sennosides-Docusate Sodium), Give 1 tablet by mouth in the morning . Review of Physician Order dated 4/2/2026, revealed . Lexapro [antidepressant] medication] Oral Tablet 10 MG (Escitalopram Oxalate), Give 1 tablet by mouth in the morning . Review of Physician Order dated 4/16/2026, revealed . Lortab [pain medication] Tablet 5-325 MG (Hydrocodone-Acetaminophen), Give 0.5 tablet by mouth two times a day . Review of Physician Order dated 4/17/2026, revealed . Lisinopril [medication used to treat high blood pressure] Oral Tablet 10 MG (Lisinopril), Give 1 tablet by mouth one time a day . Review of Physician Order dated 6/13/2026, revealed . Xanax [anitanxiety medication] Oral Tablet 0.5 MG (Alprazolam), Give 0.5 mg by mouth two times a day . Review of Physician Order dated 6/29/2026, revealed . Bactrim [used for infections] DS Oral Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim), Give 1 tablet by mouth two times a day . Observation outside Resident #49's room during medication administration on 6/30/2026 at 8:25 AM, revealed Registered Nurse (RN) C unlocked medication cart after exiting Resident #23's room and proceeded to gather the following medications of Aspirin, Senna Plus, Lexapro, Lortab, Lisinopril, Xanax, Bactrim and placed them in a medication cup, poured a glass of water, then locked the medication cart. RN C failed to sanitize hands prior to gathering the medications. RN C knocked and entered the resident's room and explained to resident what medications she had. RN C raised the head of the bed and held medication cup to residents' mouth followed by administering the water. RN C observed resident swallow medication and water, threw the empty medication and water cups into the garbage and exited the room. RN C began to gather medication for next Resident. RNC failed to sanitize hand after exiting residents #49's room and before gathering mediations for the next resident. During an interview on 6/30/2026 at 8:37 AM, RN C was asked if she should have sanitized her hands between residents. RN C stated .yes, I should have . During an interview on 6/30/2026 at 3:15 PM, the DON was asked if staff should perform hand hygiene upon exiting a resident's room. The DON stated yes, hand hygiene needs to be performed when exiting a room . The DON was asked if hand hygiene should be performed prior to gathering medication for medication administration. the DON stated hands should be sanitized before pulling medication .

Based on policy review, Hospice contract review, medical record review, facility investigation review, Hospital record review, and interview, the facility failed to ensure residents were free from neglect for 1 of 3 (Resident #1) sampled residents reviewed for injury of unknown origin. On 11/10/2022, Resident #1 was found in bed by staff with multiple bruises to her right shoulder and right upper arm. On 11/18/2022, Resident #1 complained of pain in her right shoulder area. On 11/18/2022, the facility obtained an X-ray of the right arm/shoulder that revealed a displaced acute right transverse humerus shaft fracture (broken upper right arm usually caused by trauma/injury). During the investigation on 11/18/2022 it was found that on 11/8/2022, 2 Hospice staff members (Hospice Certified Nursing Assistant (CNA) F and CNA S) transferred Resident #1 without using a mechanical lift (a device used to help transfer a resident), heard her shoulder pop, and they did not report this to any staff at the facility. The facility failed to ensure Resident #1 received proper care and treatment with an undiagnosed fracture of the right humerus for 10 days following the inappropriate transfer, which resulted in actual HARM to Resident #1. The findings include: 1. Review of the facility policy titled, Hospice Services, dated 10/1/2021, revealed .Hospice providers who contract with the facility.Are held responsible for meeting professional standards.The facility will communicate and collaborate with the hospice provider .The facility's protocols for developing and implementing a coordinated facility plan of care.The facility will collaborate with hospice to ensure the care plan is appropriate for the patient. Review of the facility's policy titled, Abuse, dated 10/1/2021, revealed .This organization recognizes and respects that each resident has the right to be free from abuse, neglect, misappropriation of resident's property, and exploitation as defined in this subpart.Neglect is the failure of the facility, it's employees or services providers to provide goods and services to residents that are necessary to avoid physical harm.The assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with communication disorders, residents that require heavy nursing care and/or are totally dependent on staff. 2. Review of the facility's contract titled, Protocol and Agreement for the Provision of [Named Hospice] Services to the Residents of [Named Facility], dated 8/27/2025, revealed .[Named Hospice] shall develop the Initial Plan of Care [POC] to be provided to [Named Facility] specifying information pertinent to the resident's treatment within 3 business days of admission. The [Named Hospice] POC will be reviewed by [Named Facility] and integrated into one Plan of Care. The [Named Hospice] POC will be reviewed by [Named Hospice] every two weeks during IDG [interdisciplinary group] and updated as necessary by [Named Hospice]. The [Named Hospice] POC shall be submitted to the [Named Facility] MDS [Minimum Data Set] staff designee at minimum on admission or as needed to properly care for residents. The facility was unable to provide a Hospice contract/agreement for the time period of Resident #1's admission to hospice on 10/21/2022. 3. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Osteoarthritis, Anxiety, Dementia, and Alzheimer's Disease. Review of the (Named Hospice) CNA Notes dated 11/8/2022, revealed .Activities.Assisted with Transfers. There was no documentation to show a mechanical lift was used. The facility was unable to provide the hospice plan of care or hospice Physician Orders for Resident #1. Review of the (Named Hospice) CNA Notes, dated 11/10/2022, revealed .Activities.Assisted with Transfers .[named mechanical lift] . Review of the Nurse's Notes dated 11/18/2022, revealed .Called to residents' [Resident #1's] room per CN [Charge Nurse]. Resident c/o pain to R arm R arm noted c [with] bruising that had previously been reported/observed. Noted with [decrease] in ROM [range of motion] to arm. Upon interviewing staff members and hospice staff members it was brought to our attention that on previous visit to facility hospice CNA's had transferred resident c 2 assist [with 2 person assist]. Resident has current POC for [named mechanical lift]. CNA stated that during transfer she heard a pop and reported to hospice nurse not facility nurse. Hospice nurse did not report incident to facility nurse either.Spoke with [Named Hospice staff] r/t findings. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 99, which indicated Resident #1 was unable to complete the interview and had moderately impaired cognitive skills for daily decision making. Resident #1 required substantial/maximal assistance from staff for eating, toileting, and bed mobility, was dependent of staff for transfers, and received hospice care. The facility was unable to provide an MDS assessment for the time period prior to 1/25/2023. 4. Review of the facility investigation Departmental Notes, dated 11/11/2022 at 8:16 AM, revealed .CNA was giving resident [Resident #1] a bed bath on 11/10/2022 at approx. [approximately] 8:30 PM when she went to turn resident she complained of her right arm and shoulder hurting. Upon inspection she found bruises along resident [Resident #1's] right upper arm. She called me to the room where I found 1 bruise to the back of right shoulder approx. 6x2 [6 centimeters (cm) long by 2 cm wide], one bruise to right AC [acromioclavicular-a joint in the shoulder where two bones meet] approx. 6.5x3 [cm], and one bruise to the back of right upper back arm approx. 8x8 [cm]. I notified the RN [Registered Nurse] on shift. I sent fax to [Named Medical Director] at approx. 8:00 AM on 11/11/22 [2022]. The facility failed to notify the Medical Director of pain and bruising to Resident #1's right shoulder area until approximately 12 hours after identification, when they sent a fax notification. Review of the facility investigation Departmental Notes, dated 11/18/2022 at 3:30 PM, revealed .Called to floor per CN [Charge Nurse] r/t [related to] resident c/o [complains of] pain to R [right] arm. Arm noted with bruising that had previously been noted and observed. ROM [range of motion] limited to fingers and pain upon touch. Spoke with [Named Medical Director] and obtained order STAT [immediate] Xray of Right arm/shoulder. Resident sent to [Named Medical Facility] for X-rays via [by way of].EMS [emergency medical services].X-ray report noting displaced fracture of R humerus [a long bone in the upper arm] splint in place, orders to follow up with ortho [orthopedic]. Review of a written witness statement dated 11/18/2022, revealed .11/8/2022.[Hospice CNA F] and I [Hospice CNA S] went to put her [Resident #1] in bed after shower. We pivot the patient an [and] her shoulder popped. Review of a written witness statement dated 11/18/2022, revealed .11/8/2022.[Hospice CNA F] called SN [Hospice LPN G] r/t pt [patient-Resident #1's] shoulder popped upon transferring pt stated to CNA that it hurt. SN [Hospice LPN G] to make a visit and vitals within normal limits for pt. Pt with no bruising or discomfort noted @ [at] this x [time] to R [right] shoulder. Told CNA to evaluate upon next visit. No other issues noted. Review of a written witness statement dated 11/22/2022, revealed .While transferring patient her right arm pooped [popped]. I [Hospice CNA F] called her hospice LPN and reported it. Patient didn't complain No nurse or CNA was at the desk when I left. 5. Review of the (Named Hospital) Diagnostic Radiology report dated 11/18/2022, revealed .Findings .Frontal and lateral views of the right humerus [upper arm]. Transverse fracture proximal humerus shaft [break that occurs across the bone near the shoulder] with greater than one [bone] shaft width's displacement and 2.0 cm overlap. Generalized osteopenia. Right shoulder osteoarthritis. Impression .Displaced acute right humerus shaft fracture . 6. Resident #1's pain and bruising to the upper right upper arm and shoulder were identified on 11/10/2022, and on 11/18/2022 an X-ray revealed a right humerus fracture. The facility was unable to provide documentation they had interviewed or attempted to interview Hospice employees who recently provided care to Resident #1 prior to the bruising being identified, when attempting to identify the cause of the bruising on 11/10/2022. Witness statements from Hospice employees that revealed an incident that occurred on 11/8/2022, were not obtained until after the fracture was identified on 11/18/2022. During a phone interview on 10/22/2025 at 11:35 AM, Hospice CNA F stated that she did not recall any incidents involving Resident #1 during 11/2022. During a phone interview on 10/22/2025 at 11:42 AM, Hospice LPN G stated that she did not recall any incidents involving Resident #1 during 11/2022. During a phone interview on 10/22/2025 at 12:17 PM, ADON H was asked if she recalled Resident #1's right humerus fracture found on 11/18/2022. ADON H recalled Resident #1 was on hospice and a hospice aid came into the facility to give a bath and the hospice aid said she had heard a pop in [the] Resident's right arm/shoulder. A fracture was found and investigated. Resident #1 was sent to [Named Orthopedic Center] and was not a candidate for surgery, a sling was recommended. ADON H was asked what was done to determine the cause of the injury. ADON H stated, .We had gone back to all the staff that had cared for her.I asked the Hospice aide.They did a transfer with 2 people but did not use the Hoyer lift.they heard a pop.Routinely we educated the hospice agency about the resident's care plan books and the location of those books. They are asked to review the resident's care plans. ADON H was asked who was notified about the X-ray results and what was done related to those findings. ADON H stated, .the Abuse Coordinator was the Administrator, it was reported to him, and because it was clinical I reported back to him all the findings.We provided education .It was all done the same day 11/18/2022 [10 days after hospice CNAs heard a pop when they transferred Resident #1 inappropriately, and 8 days after the bruising was identified]. The facility was unable to provide documentation of the education provided and on what date these occurred. During a telephone interview on 10/22/2025 at 1:38 PM, LPN I was asked what the facility did when bruising was found to Resident #1's right upper arm and shoulder on 11/10/2022. LPN I stated, I called the DON [Director of Nursing].put in an Incident report.sent a fax to [Named Medical Director].I know they [the administration staff] called staff members and talked to them.We were told to monitor and be careful around the area and use 2 persons when providing care for her. The facility was unable to provide documentation of facility staff interviews, skin assessments, or staff training following Resident #1's fractured humerus identified on 11/18/2022. During an interview on 10/22/2025 at 4:22 PM, the Administrator was asked if a thorough investigation was completed related to Resident #1's bruising to right upper arm and back found on 11/10/2022. The Administrator stated .I would say yes, we provided education to our staff, unfortunately I cannot produce that education for you. The Administrator was asked what was determined to be the cause of the bruises. The Administrator stated .it was the lift sling.I cannot produce anything for that.without access to previous records. At that moment of time, we found a cause for the bruises and provided education. I cannot provide it. I do not have access. The Administrator was asked what do you see when you look at the incident report you have provided us for 11/10/2022. The Administrator stated, .I see bruises without a cause listed.I can't provide the documentation for the investigation for 11/10/2022, I do not have access to those records. The Administrator was asked per the facility policy should all injuries of unknown origin be reported. The Administrator stated, Yes, per our new policy. I can't tell you what the old policy said. I don't have access to the old policy. The Administrator was asked what was determined to be the cause of the fracture revealed on 11/18/2022 to Resident #1's right humerus. The Administrator stated, .Root cause analysis determined the CNAs did not use the lift sling.transferred resident per 2 person assist. The Administrator was asked if surveyors should be able to see those records. The Administrator stated, .Yes, you should be able to see them, however I am unable to produce them due to lack of cooperation from our previous owners. Refer to F-842

Based on the policy review, Electronic Medical Record (EMR) Provider Transition Checklist memo review, Administrator's email, medical record review, and interview, the facility failed to maintain access and availability to resident's medical records for 10 of 10 (Resident #1, #3, #5, #6, #7, #8, #9, #10, #11, and #12) sampled residents reviewed for medical records prior to 6/18/2024. The findings include: 1. Review of the RETENTION OF MEDICAL RECORDS, policy dated 10/1/2021, revealed .Medical records shall be retained by the facility in accordance with current applicable federal and state laws.Medical records of discharged residents will be retained for period required by State law.Six years from the date of discharge when there is no requirement in State law. Review of the undated facility policy titled, Resident Rights, revealed .The Facility shall protect and promote the rights of each Resident, including each of the following rights.The Resident or Legal Representative has the right, upon oral or written request, to access all records pertaining to himself or herself, including clinical records. Review of the undated [Named EMR Provider]Transition Checklist, memo, revealed, .Unfortunately, we were notified yesterday [5/28/2024] that we will not be given continued access to [Named EMR] after [Named Company] takes ownership on 6/1/2024 You will be documenting fully on paper starting at midnight on 6/1/2024 through 7/16/2024.The full clinical module of [Named EMR Provider] will be completed on 7/16/2024.Ensure all staff know they can't document in [Named EMR].6/1/2024. Review of a facility provided email dated 10/13/2025 at 9:13 AM, revealed the Administrator wrote an email to the previous owners of the facility. The email stated, .State surveyors have come to [Named Facility] on a complaint from before our transition. They are asking for access to [Named EMR] as this was the EMR that was used during this time. Review of the reply email dated 10/13/2025 at 9:27 AM, from Chief Executive Officer (CEO) E stated, Unfortunately [Named EMR] no longer exists. [Named EMR] shut down nothing we can do about that. 2. Review of the medical record review revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Hypertension, Chronic Pain Syndrome, Heart Failure and Anxiety. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated Resident #1 was severely cognitively impaired. The facility was unable to access or provide medicals record for Resident #1 prior to 6/18/2024. 3. Review of the medical record review revealed Resident #3 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Fall, Chronic Kidney Disease, and Cardiomegaly (an enlarged heart). Review of the significant change status MDS dated [DATE], revealed Resident #3 had a BIMS score of 13, which indicated Resident #3 was cognitively intact. The facility was unable to access or provide medicals record for Resident #3 prior to 6/18/2024 4. Review of the medical record review revealed Resident #5 was admitted to the facility on [DATE], with diagnoses including Schizophrenia, Heart Disease, Anxiety, and Encephalopathy. Review of the quarterly MDS dated [DATE], revealed Resident #5 had a BIMS score of 15, indicating Resident #5 was cognitively intact. The facility was unable to access or provide medicals record for Resident #5 prior to 6/18/2024. 5. Review of the medical record review revealed Resident #6 was admitted to the facility on [DATE], with diagnoses including Hemiplegia, Parkinson's Disease, Hypertension, and Dysphagia. Review of the annual MDS dated [DATE], revealed Resident #6's BIMS score was not assessed. The facility was unable to access or provide medical records for Resident #6 prior to 6/18/2024. 6. Review of the medical record review revealed Resident #7 was admitted to the facility on [DATE], with diagnoses including Heart Failure, Guillain-Barre Syndrome and Acute Kidney Failure. Review of the significant change of status MDS dated [DATE], revealed Resident #7 had a BIMS score of 15, which indicated Resident #7 was cognitively intact. The facility was unable to access or provide medical records for Resident #7 prior to 6/18/2024. 7. Review of the medical record review revealed Resident #8 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Chronic Obstructive Pulmonary Disease, Diabetes, and Atrial Fibrillation. Review of the admission MDS dated [DATE], revealed Resident #8 rarely/never understood. The facility was unable to access or provide, medical records for Resident #8 prior to 6/18/2024. 8. Review of the medical record review revealed Resident #9 was admitted to the facility on [DATE] with diagnosis including Diabetes, Guillain-Barre Syndrome, Peripheral Vascular Disease, Diabetes and Depression. Review of the quarterly MDS dated [DATE], revealed Resident #9's BIMS score was not assessed. The facility was unable to access or provide, medical records for Resident #9 prior to 6/18/2024. 9. Review of the medical record review revealed Resident #10 was admitted to the facility on [DATE], with diagnoses including Paraplegia, Heart Disease, Chronic Pain Syndrome, and Cardiac Pacemaker. Review of the quarterly MDS dated [DATE], revealed Resident #10 had a BIMS score was 15, which indicated Resident #10 was cognitively intact. The facility was unable to access or provide medical records for Resident #10 prior to 6/18/2024. 10. Review of the medical record review revealed Resident #11 was admitted to the facility on [DATE], with diagnoses including Paraplegia, Heart Disease, Chronic Pain Syndrome, and Cardiac Pacemaker. Review of the quarterly MDS dated [DATE], revealed Resident #11 had a BIMS score of 15, which indicated Resident #11 was cognitively intact. The facility was unable to access or provide medical records for Resident #11 prior to 6/18/2024. 11. Review of the medical record review revealed Resident #12 was admitted to the facility on [DATE], with diagnoses including Hypertensive Kidney Disease, Parkinson's Disease, Dementia, and Tremors. Review of the quarterly MDS dated [DATE], revealed Resident #12 had a BIMS score of 3, which indicated Resident #12 was severely cognitively impaired. The facility was unable to access or provide medical records for Resident #12 prior to 6/18/2024. During an interview on 10/22/2025 at 4:22 PM, the Administrator was asked about the dates of the company's transition. The Administrator stated, [Named previous facility owner] ended 6/18/2024 at 12:01 AM, we had to go to paper documentation. [Named EMR] went live on 7/16/2024. The Administrator was asked how long should records be kept and accessible to the facility, residents and outside entities. The Administrator stated, It's either 7 or 10 years . The Administrator was asked who has current access to these records prior to 6/18/2024. The Administrator stated, I would say someone with the old [Named previous facility owner.] The Administrator was asked, have you been successful in retrieving any of these medical records. The Administrator stated, No.

Based on facility policy review, medical record review, facility investigation review, Hospital record review, and interview, the facility failed to report an injury of unknown origin for 1 of 3 (Resident #1) sampled residents reviewed for abuse and neglect. The findings include: 1. Review of the facility policy titled, Abuse, dated 10/1/2021, revealed .This organization recognizes and respects that each resident has the right to be free from abuse, neglect, misappropriation of resident's property, and exploitation as defined in this subpart.Reporting.The organization will maintain systems to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source.are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury.including to the State Survey Agency and adult protective services.in accordance with State law through established procedures. 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Osteoarthritis, Anxiety, Dementia, and Alzheimer's Disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 99, which indicated Resident #1 was unable to complete the interview and had moderately impaired cognitive skills for daily decision making. Resident #1 required substantial/maximal assistance from staff for toileting, and bed mobility, and was dependent on staff for transfers. Resident #1 received hospice services. The facility was unable to provide an MDS for the time period prior to 1/25/2023. Review of the facility investigation Departmental Notes, dated 11/11/2022 at 8:16 AM, revealed Resident #1 complained of her right arm and shoulder hurting while being repositioned during her bed bath at approximately 8:30 PM on 11/10/2022. Assessment by the Nurse revealed multiple bruises along Resident #1's right upper arm, including one bruise to the back of the right shoulder, one bruise to the right AC [acromioclavicular-a joint in the shoulder where two bones meet], and one bruise to the back of the right upper back of arm. Review of the facility's Resident Incident Report dated 11/10/2022, revealed .Incident Type: bruise.Location.Resident Room.Activity at time.Unknown.Incident Reported by CNA K.Report Prepared by.LPN I.Incident level.Non-Witnessed. Review of the facility investigation Departmental Notes, dated 11/18/2022 at 3:30 PM, revealed .Called to floor per CN r/t [related to] resident c/o [complains of] pain to R [right] arm. Arm noted with bruising that had previously been noted and observed. ROM [range of motion] limited to fingers and pain upon touch. Spoke with [Named Medical Director] and obtained order STAT [immediate] X-ray of Right arm/shoulder. Resident sent to [Named Medical Facility] for X-rays via [by way of] .EMS [emergency medical services] .X-ray report noting displaced fracture of R humerus [a long bone in the upper arm] splint in place, orders to follow up with ortho [orthopedic]. Review of the (Named Hospital) radiology report dated 11/18/2022, revealed . XR [X-ray] humerus right.Transverse fracture [a type of fracture that runs opposite the direction of the bone] proximal [the end nearer to the point of connection to the body] humerus shaft [the long portion of the bone] with greater than one shafts width's displacement and 2.0 cm overlap.Generalized Osteopenia [a loss of bone density].Right shoulder Osteoarthritis.Impression.Displaced acute [a fracture caused by injury] right humerus shaft fracture. During an interview on 10/21/2025 at 1:35 PM, the Administrator was asked if the fracture to the right humerus identified on 11/18/2022 was reported as an injury of unknown origin. The Administrator stated, .I did not report it because it was an injury of unknown origin and not from willful intent to harm. During a phone interview on 10/22/2025 at 2:25 PM, the Medical Director was asked if all injuries of unknown origin should be reported. The Medical Director stated, Yes, they should. During an interview on 10/22/2025 at 4:22 PM, the Administrator was asked to review the incident report that had been provided to the surveyors by the facility related to Resident #1's bruising to right upper arm and right upper back of arm identified on 11/10/2022. The Administrator was then asked what do you see when you look at the incident report for 11/10/2022. The Administrator stated, I see bruises without a cause listed. The Administrator was asked if injuries of unknown origin should be reported. The Administrator stated, that if that was all the information they had it would have been reported, but root cause analysis led them to the lift sling as the cause of the bruising. The Administrator was asked where the documentation was that showed that determination and the investigation process involved. The Administrator stated, I can't provide the documentation for the investigation for 11/10/2022, I do not have access to those records. The Administrator was asked per facility policy should all injuries of unknown origin be reported. The Administrator stated, .Yes per our new policy. I can't tell you what the old policy said. I don't have access to the old policy. The Administrator was asked was this injury reported. The Administrator stated, No, it was not.

Based on policy review, medical record review, facility investigation review, Hospital record review, and interview, the facility failed to perform a thorough investigation for injury of unknown origin for 1 of 3 (Resident #1) sampled residents reviewed for abuse and neglect. The findings include: 1. Review of the facility policy titled, Abuse, dated 10/1/2021, revealed .Investigation Designated staff will immediately review and investigate all allegations .of abuse .The results of all investigation are to be communicated to the administrator or his or her designated representative and to other officials in accordance with the State law, including the State Survey Agency, within 5 working days of the incident .The organization will conduct analysis for trends and patterns related to .injuries of unknown origin . Review of the facility policy titled, Accidents and Incidents- Investigating and Reporting, dated 10/1/2021, revealed .All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator.Accident; refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident.The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly reported the accident to the administrator/designee and will initiate and document investigation of the accident or incident.The following data, as applicable shall be included on the Report of Incident/Accident form:.The date and time the accident or incident took place.The nature of the injury/illness.The circumstances surrounding the accident or incident. Where the accident or incident took place.The name(s) of witnesses and their accounts of the accident or incident.The injured person's account of the accident or incident.The time the injured person's attending physician/practitioner was notified, as well as the time the physician/practitioner responded and his or her instructions.The date/time the injured person's representative was notified and by whom.The condition of the injured person, including his/her vital signs.The disposition of the injured (i.e., transferred to hospital, put to bed, sent home, returned to work, etc.).Any corrective action taken.follow-up information.Other pertinent data as necessary or required.The signature and title of the person completing the report. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Osteoarthritis, Lack of Coordination, Congestive Heart Failure, Alzheimer's and Dementia. Review of the facility's Post-Incident Actions form dated 11/10/2022, revealed the facility failed to provide immediate post-incident action or immediate actions taken related to the incident. Review of the facility investigation Departmental Notes dated 11/11/2022 at 8:16 AM, revealed .CNA [Certified Nursing Assistant] was giving resident a bed bath on 11/10/2022 at approx. [approximately] 8:30 PM when she [CNA] went to turn resident she [Resident #1] complained of her right arm and shoulder hurting. Upon inspection she found bruises along resident right upper arm. She called me to the room where I found 1 bruise to the back of right shoulder approx. 6x2 [centimeters [cm], one bruise to right AC [acromioclavicular joint [a joint in the shoulder where two bones meet] approx. 6.5x3 [cm], and one bruise to the back of right upper back arm approx. 8x8 [cm]. I notified the RN [Registered Nurse] on shift. I sent fax to [Named Medical Director] at approx.[approximately] 8:00 AM on 11/11/22. I attempted to call son [Named Resident #1's son] at 7:49 AM with no answer and unable to leave a voicemail. BP [blood pressure] 129/70-, P [pulse] 72, R [respirations] 20, t [temperature] 98.4, o2 [oxygen saturation] 94% [percent] . The facility was unable to provide documentation related to the determination of the cause of the bruising, interventions to prevent reoccurrence, staff interviews, the physician response or instructions regarding the incident, or staff education related to incident on 11/10/2022. Review of the facility investigation Departmental Notes dated 11/18/2022 at 3:30 PM, revealed, .Called to floor per CN [Charge Nurse] r/t [related to] resident c/o [complaints of] pain to R [right] arm. Arm noted with bruising that had previously been noted and observed. ROM [range of motion] limited to fingers and pain upon touch .Resident returned to facility from [Named Medical Center] with Xray report noting displaced fracture of R humerus . Review of the Nurses Notes dated 11/18/2022, revealed .Called to residents [Resident #1] room pe CN [Charge Nurse] Resident c/o pain to R arm R arm noted with bruising that had previously been reported/observed. Noted with [arrow pointing down[decrease] in ROM to arm . Resident #1 presented with complaints of pain and bruising to right upper arm on 11/10/2022, and on 11/18/2022 Resident #1 had an X-ray of the right upper arm/shoulder due to pain and a decline in range of motion that revealed a right humerus fracture. The facility was unable to provide an investigation to determine the cause of the injuries until 11/18/2022, at which point the facility was also unable to provide the education and training material provided to staff. Review of the X-Ray report dated 11/18/2022, revealed a displaced acute right humerus fracture (sudden broken right upper arm usually from trauma). The facility was unable to provide documentation to show hospice residents were assessed in relation to the 11/18/2022 incident involving Resident #1. Review of the In-service Training sheet dated 11/18/2022, revealed .Instructor [ADON H].Subjects.Resident care plans related to transferring status. The in-service was signed by staff members from multiple hospice agencies. The facility was unable to provide documentation of the In-service materials/ education provided on 11/18/2022. Review of Hospice LPN G's witness statement dated 11/18/2022, revealed, .11/8/2022.CNA called [Hospice LPN G] r/t pt [patient] shoulder popped upon transferring pt [.] pt stated to CNA it hurt. SN to make a visit and vitals within normal limits for pt, pt with no bruising or discomfort noted at this x to right shoulder. Told CNA to evaluate upon next visit. No other issues noted. Review of Hospice CNA S's witness statement dated 11/18/2022, revealed .11/8/22 [11/8/2022] .[Hospice CNA F] and I [Hospice CNA S] went to put her [Resident #1] in bed after shower. We pivot the patient an [and] her shoulder popped .After we called [Hospice LPN G]. We used a [mechanical] lift to put her back in bed. Review of Hospice CNA F's written witness statement dated 11/22/2022, revealed, .While transferring patient her right arm pooped (popped). I called her hospice LPN and reported it. Patient didn't complain no nurse or CNA was at the desk when I left. The facility was unable to provide the Incident/Accident form for the 11/18/2022 incident for Resident #1. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score was unable to be completed. Resident #1 was moderately impaired for decision making skills. Resident #1 had impairment on 1 side of upper extremities. No falls or surgery were noted. During a phone interview on 10/22/2025 at 2:25 PM, the Medical Director was asked if following the discovery of the multiple bruising on 11/10/2022 and a right humerus fracture on 11/18/2022 if there should have been a thorough investigation completed to determine the cause and prevent reoccurrence for Resident #1. The Medical Director stated, .Yes. During an interview on 10/22/2025 at 4:22 PM, the Administrator was asked if a thorough and complete investigation was completed to determine the cause of Resident #1's injuries noted on 11/10/2022 and 11/18/2022. The Administrator stated, .we stated we provided education to our staff, unfortunately I cannot produce that education for you guys. The Administrator was asked if anything else could be provided for those investigations. The administrator stated, , .I do not have access to those records. Review of the facility documentation for Resident #1 for injury of unknown origin, revealed an incomplete investigation for dates 11/10/2022 and 11/18/2022.

Based on policy review, observation, and interview the facility failed to ensure medications were stored appropriately and securely when external medications and internal medications were stored together, and expired medications were in 4 of 7 medication storage areas (Treatment Cart, North Hall Medication Cart, West Hall Medication Cart, and West Hall Medication Room) reviewed and when 1 of 3 nurses (Licensed Practical Nurse (LPN) #1) gave the South Hall Medication Cart and Medication Room keys to the to an unauthorized staff member (the Housekeeping Supervisor) and left him unattended in the Medication Room. The findings include: Review of the facility's policy titled, Storage of Medications, revised 2007, revealed .The facility shall store all drugs in a safe, secure and orderly manner .The facility shall not use discontinued, outdated, or deteriorated drugs .All such drugs shall be returned to the dispensing pharmacy or destroyed .Drugs for external use .shall be stored separately from regular medications .Compartments .containing drugs and biologicals shall be locked when not in use and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others .Only persons authorized to prepare and administer medications shall have access to the medication room, including any keys . Observation at the South Hall Nurses' Station on 1/19/2022 at 8:30 AM, revealed LPN #1 gave the keys to the South Hall Medication Cart and Medication Room to the Housekeeping Supervisor and walked down the hall, out of sight of the Medication Room, to dispose of a dirty pillow case. LPN #1 then returned to the Nurses' Station and opened the Medication Room door for the Housekeeping supervisor, who entered the Medication Room. LPN #1, then returned to the Medication Cart in the hallway, leaving the Housekeeping Supervisor in the Medication Room unattended. Observation of the Treatment Cart on 1/19/2022 at 2:14 PM, revealed 1 tube of [MEDICATION(S)] (an antibiotic) topical ointment with an expiration date of 11/2021 and 1 tube of [MEDICATION(S)] (a medication used to remove damaged tissue from wounds) with an expiration date of 12/2021 in the bottom drawer. During an interview on 1/19/2022 at 2:16 PM, the Treatment Nurse confirmed expired medications should not be stored on the Treatment Cart. Observation of the North Hall Medication Cart on 1/20/2022 at 4:36 PM, revealed 1 box containing a pure and gentle enema stored in a drawer with bottles of oral medications. Observation of the West Hall Medication Cart on 1/20/2022 at 4:44 PM, revealed 1 box containing a pure and gentle enema stored with oral medications. Observation of the West Hall Medication Room on 1/20/2022 at 4:51 PM, revealed 1 box of [MEDICATION(S)] cough [MEDICATION(S)] with an expiration date of 10/2021. During an interview on 1/20/2022 at 4:59 PM, the Assistant Director of Nursing (ADON) was asked who should have access to the keys to the medication carts and medication rooms. The ADON confirmed that only Charge Nurses, the Registered Nurse Supervisor, the ADON, and the Director of Nursing should have access to medication cart and medication room keys. The ADON was asked if medication cart keys should be given to an unlicensed staff member. The ADON stated, No. The ADON was asked if an unlicensed staff should be left unattended in the Medication Room. The ADON stated, No. The ADON confirmed expired medications should not be stored in medication or treatment carts and internal and external medications should be stored separately.

Based on policy review, medical record review, observation, and interview, the facility failed to promote care that maintained residents' dignity, respect, and quality of care when staff failed to provide dignity bags for 2 of 2 sampled residents (Resident #26 and #63) reviewed for urinary catheters. The findings include: Review of the facility's policy titled, Quality of Life - Dignity, revised on 8/2009, revealed .Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality .Helping the resident to keep urinary catheter bags covered . Review of the medical record, revealed Resident #26 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation in the resident's room on 1/20/2022 at 9:00 AM, revealed Resident #26's indwelling urinary catheter bag was not covered, and the urine in the drainage bag was visible. Review of the medical record, revealed Resident #63 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation in the resident's room on 1/18/2022 at 10:53 AM, 2:57 PM, and 4:26 PM, on 1/19/2022 at 8:16 AM and 2:57 PM, and on 1/20/2022 at 8:40 AM, revealed Resident #63's indwelling catheter bag was not covered, and the urine in the drainage bag was visible. During an interview on 1/19/2022 at 4:47 PM, the Director of Nursing (DON) was asked if an indwelling urinary catheter bag should be covered to protect the resident's dignity. The DON stated, Yes Ma'am.

Based on review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.17.1, dated October 2019, medical record review, and interview, the facility failed to ensure Death in Facility tracking assessments were completed for 2 of 23 sampled residents (Resident #2 and #8) reviewed for Minimum Data Set (MDS) assessments. The findings include: Review of the CMS Long-Term Care RAI 3.0 User's Manual version 1.17 pages 2-10 and 2-18, revealed .The facility must complete a Death in Facility tracking record MDS completion date .No later than .Discharge (Death)date + 7 calendar days . Review of the medical record, revealed Resident #2 was admitted to the facility on [DATE] and discharged on [DATE], due to a death in the facility. A Death in Facility assessment should have been completed on 9/10/2021. The facility was unable to provide a Death in Facility MDS assessment for Resident #2. Review of the medical record, revealed Resident #8 was admitted to the facility on [DATE] and discharged on [DATE], due to a death in the facility. A Death in Facility assessment should have been completed on 11/8/2021. The facility was unable to provide a Death in Facility MDS assessment for Resident #8. During an interview on 1/20/2022 at 12:55 PM, the Assistant Director of Nursing confirmed Death in Facility MDS assessments were not competed for Resident #2 and #8.

Based on review of the Center for Disease Control (CDC) and Prevention guidelines, facility policy review, social media review, observation, and interview, the facility failed to prevent the risk of transmission of COVID-19 for 2 sampled residents (Resident #1 and #2) of the 11 residents attending a wedding ceremony, which had the potential to result in transmission of [MEDICAL CONDITION] to these 11 residents. The findings include: Review of the CDC guidelines dated 3/2020, showed that the COVID-19 virus is thought to be spread mainly from person-to-person, between people who are in close contact with one another (within about 6 feet). The CDC guidelines recommended social distancing, also called physical distancing, which means keeping space between yourself and other people outside your home, to practice social or physical distancing: Stay at least 6 feet from other people, and do not gather in groups. Those at high-risk for severe illness from COVID-19 are: people [AGE] years and older and people who live in a nursing home or long-term care facility. Review of the facility's policy titled, Infection Control Covid-19, dated 3/11/2020, showed that facility prevention efforts included: staff, residents, and visitors should maintain social distances of 6 feet or greater. Review of social media photo postings dated 3/27/2020, showed 11 residents were not distanced at least 6 feet apart when they attended a wedding ceremony held at the facility. Review of the medical record, showed Resident #1 had [DIAGNOSES REDACTED]. Observation in the hallway on 4/2/2020 at 10:45 AM, showed Resident #1 was alert with confusion. She was dependent on staff to provide mobility by wheelchair, transfers, and other activities of daily living. Review of the medical record, showed Resident #2 had [DIAGNOSES REDACTED]. Observation in the hallway on 4/2/2020 at 1:40 PM, showed Resident #2 was alert with confusion. She was dependent on staff for activities of daily living including transfers and mobility in wheelchair. During an interview conducted on 4/2/2020 at 11:55 AM, the Director of Nursing (DON) confirmed that Resident #1 and Resident #2 attended a wedding ceremony with 9 other residents and staff on 3/27/2020, and social distancing was not practiced. The DON revealed the facility's main entrance doors were left open and staff went in and out of the main entrance to setup decorations for the ceremony. The residents were lined up at the main entrance hallway. During an interview conducted on 4/2/2020 at 3:27 PM, the Assistant Director of Nursing (ADON) confirmed that the facility did not follow social distancing during a wedding ceremony on 3/27/2020 and the main entrance doors were left open. During an interview conducted on 4/2/2020 at 3:45 PM, the Regional Quality Specialist confirmed that the facility staff did not follow the CDC guidelines for social distancing.

Based on facility policy review, medical record review, and interview, the facility failed to timely notify the physician of a change in a resident's condition related to a pressure ulcer for 1 of 2 (Resident #50) sampled residents reviewed for pressure ulcers. The failure of the facility to timely notify the physician of a heel wound and obtain orders for treatment resulted in actual Harm for resident #50 when the wound deteriorated from a reddened area to a deep tissue injury/pressure ulcer. The findings included: The facility's Pressure Ulcer/Injury Risk Assessment policy dated 7/17, documented, .The purpose of this procedure is to provide guidelines for the structured assessment and identification of residents at risk of developing pressure ulcers/injuries .If a new skin alteration is noted .Notify attending MD (physician) .notify family, guardian . Medical record review revealed Resident #50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Departmental Notes written by Licensed Practical Nurse (LPN) #1 dated 5/28/18 documented, .noted blister to right heel approx. (approximately) 1 in. (inch) diameter . Observation in Resident #50's room on 6/26/18 at 4:46 PM revealed Licensed Practical Nurse (LPN) #1 removed the heel protector and the dressing from Resident #50's right heel revealing a dark dry area to the bottom of the heel. The wound was not identified as a DTI by the staff until the surveyor requested to look at Resident #50's heels. Interview with the Wound Nurse on 6/26/18 at 5:40 PM, in the Administrator's office, the Wound Nurse was asked when she completed the last skin inspection for Resident #50, and what were the findings. The Wound Nurse stated, .June 19 .the right heel was just red and bubbly and still blanchable .the MD was notified yesterday (6/25/18) .got an order today for the wound . The Wound Nurse was asked when she identified a wound, how were her findings communicated to the staff. The Wound Nurse stated, .sometimes I don't write it down, I just keep it in my head . The Wound Nurse was asked why the skin inspection sheets documented that the skin was intact if Resident #50 had a wound on her right heel. The Wound Nurse stated, .there was nowhere to document. The Wound Nurse was asked if the physician had been notified on 5/28/18 when the wound was identified. The Wound Nurse stated, .no I just notified him today (6/26/18) . There were inconsistencies by the Wound Nurse of the description of the wound and when she notifed the MD. The facility failed to notify the physician of a new pressure ulcer for Resident #50 for 29 days after identification.

Based on facility policy review, medical record review, observation, and interview the facility failed to revise the care plan to identify the development of a pressure ulcer for 1 of 2 (Resident #50) sampled residents reviewed with pressure ulcers. The failure of the facility to accurately perform skin assessments and revise Resident #50's care plan with updated interventions to address a reddened area when it was identified resulted in actual Harm to Resident #50. The findings included: The facility's Pressure Ulcer/Injury Risk Assessment policy dated 7/17, documented, .Steps in the Procedure .develop the resident centered care plan and interventions based on the risk factors identified in the assessments, the condition of the skin, the residents overall critical condition .Once inspection of skin is completed document the findings on a facility-approved skin assessment tool .If new skin alteration is noted, initiate a (pressure or non-pressure) form related to the type of alteration in skin .The care plan must be modified as the resident's condition changes, or if current interventions are deemed inadequate . Medical record review revealed Resident #50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #50's care plan last updated on 5/10/18 did not reflect the current status of Resident #50's skin integrity related to a Deep Tissue Injury that was identified 5/28/18. There was no documentation on the care plan that the wound was identified 5/28/18 or any interventions were implemented. Review of a Departmental Note written by Licensed Practical Nurse (LPN) #1 dated 5/28/18 documented, .noted blister to right heel approx. (approximately) 1 in. (inch) in diameter. no open areas noted. no c/o (complaint of) pain . Observations in Resident #50's room on 6/26/18 at 11:05 AM revealed Resident #50 sitting up in a wheelchair with heel protectors on. Interview with LPN #1 on 6/26/18 at 3:08 PM, at the North Nurses' Station, LPN #1 was asked if Resident #50 had any skin issues. LPN #1 stated, .yes . Observations in Resident #50's room on 6/26/18 at 4:46 PM revealed LPN #1 removed the heel protector and the dressing from Resident #50's right heel revealing a dark dry area to the bottom of the heel. The wound was not identified as a DTI by the staff until the surveyor requested to look at Resident #50's heels. The Departmental Notes written by the Wound Nurse dated 6/26/18 documented, .This am (morning) resident noted with dti to right heel measuring 1.0 cm. (centimeters) x (by) 1.4 cm. Area previously noted with redness . Interview with the Director of Nursing (DON) on 6/27/18 at 8:17 AM, in the Administrator's office, the DON was asked if newly identified pressure ulcers should be reflected on the care plan. The DON confirmed care plans should be updated.

Based on National Pressure Ulcer Advisory Panel (NPUAP) reference guide, facility policy review, medical record review, observation, and interview, the facility failed to perform an accurate skin assessment to identify a pressure ulcer, failed to notify the physician of the development of a new pressure ulcer, failed to obtain new treatment orders, and failed to accurately assess a wound before it deteriorated to a Deep Tissue Injury (DTI) for 1 of 2 (Resident #50) sampled residents reviewed for pressure ulcers. The failure of the facility to accurately assess, implement interventions and document the findings before the pressure ulcer progressed into a Deep Tissue Injury (DTI) resulted in actual Harm for Resident #50. The facility failed to notify the physician, failed to obtain physician's orders [REDACTED].>The findings included: Review of the NPUAP quick reference guide defined a Suspected Deep Tissue Injury (DTI): with unknown depth as a .Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue .evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue . The facility's Pressure Ulcer/Injury Risk Assessment policy dated 7/17, documented, .The purpose of this procedure is to provide guidelines for the structured assessment and identification of residents at risk of developing pressure ulcers/injuries .Steps in the procedure .Once inspection of skin is completed document the findings on a facility-approved skin assessment tool .If a new skin alteration is noted, initiate a (pressure or non-pressure) form related to the type of alteration of skin .Documentation .The following should be recorded in the resident's medical records .the condition of the resident's skin .Initiation of a (pressure or non-pressure) form related to the type of alteration in the skin if any new skin alterations noted .Document in medical record addressing MD (Medical Doctor) notification if new skin alteration noted with change of plan of care .Documentation in medical record addressing family, guardian or resident notification if new skin alteration noted with change on plan of care .Reporting .Notify attending MD if new skin alteration noted .notify family, guardian .if new skin alteration noted . The facility's Pressure Ulcer/Skin Breakdown-Clinical Protocol policy dated 3/14, documented, .The nurse shall describe and document/report the following .full assessment of pressure sore including location, stage, length, width, and depth, presence of exudates or a necrotic tissue .The physician will authorize prudent orders related to wound treatments, including wound cleansing and debridement approaches, dressings .and application of topical agents . Medical record review revealed Resident #50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) with an assessment reference date of 5/11/18 documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #50 was cognitively intact. Resident #50 required extensive assistance with bed mobility and transfers and was at risk of developing pressure ulcers. The Departmental Notes written by Licensed Practical Nurse (LPN) #1 dated 5/28/18 documented, .noted blister to right heel approx. (approximately) 1 in. (inch) diameter . The Departmental Notes written by the Wound Nurse dated 6/26/18 documented, .This am (morning) resident noted with dti to right heel measuring 1.0 cm. (centimeters) x (by) 1.4 cm. Area previously noted with redness . The care plan updated 5/10/18 documented, .At risk for altered skin integrity .Approaches .Weekly skin audits .6/1/18 .Bilateral heel protectors as resident tolerates . Review of physician progress notes [REDACTED].Special care to avoid heel decubitus . Review of the facility's weekly Skin Inspection Report revealed documentation that Resident #50's skin was intact from 5/1/18 through 6/26/18. Review of a handwritten statement signed by Resident #50 when asked how long the nurse had been treating her right heel documented, .the Nurse had been treating it she (Resident #50) stated for some time . Review of a signed statement by the Wound Nurse dated 6/27/18 documented, I (Named Wound Nurse) as the wound nurse have been treating (Named Resident #50) Right Heel for DTI without order and Dr. notification . The facility was unable to provide documentation of any wound assessments for the right heel pressure ulcer from the time of wound identification on 5/28/18 until 6/26/18. The failure of the facility to accurately access and document findings before the reddened pressure area deteriorated into a DTI on Resident #50's right heel resulted in actual Harm to Resident #50. Observations in Resident #50's room on 6/26/18 at 11:05 AM revealed Resident #50 sitting up in wheelchair with heel protectors on. Interview with LPN #1 on 6/26/18 at 3:08 PM, at the North Nurses' Station, LPN #1 was asked if Resident #50 had any skin issues. LPN #1 stated, .yes . Observations in Resident #50's room on 6/26/18 at 4:46 PM revealed Licensed Practical Nurse (LPN) #1 removed the heel protector and the dressing (no date or initials when applied) from Resident #50's right heel revealing a dark dry area to the bottom of the heel. The wound was not identified as a DTI by the staff until the surveyor requested to look at Resident #50's heels. Interview with Wound Nurse on 6/26/18 at 5:05 PM, in the hall by the dining room, the Wound Nurse stated, .Yesterday it was real red, I put [MEDICATION NAME] (an antiseptic used for skin disinfection) and [MEDICATION NAME] (an adhesive dressing) on the wound to try to contain it .measured it today . The Wound Nurse was then asked what you would stage the wound at today. The Wound Nurse stated, A DTI . The Wound Nurse was asked what is the facility's policy regarding newly identified wounds. The Wound Nurse stated, .It was just red not open. The Doctor was notified and he said continue the heel protectors . The Wound Nurse was asked how information about wounds is relayed to the other staff involved in a resident's care. The Wound Nurse stated, .I chart in the wound notes. The nurses have access to them . Interview with the Wound Nurse on 6/26/18 at 5:40 PM, in the Administrator's office, the Wound Nurse was asked when she completed the last skin inspection for Resident #50, and what were the findings. The Wound Nurse stated, .June 19 .the right heel was just red and bubbly and still blanchable .the MD was notified yesterday (6/25/18) .got an order today for the wound . The Wound Nurse was asked when she identified a wound, how were her findings communicated to the staff. The Wound Nurse stated, .sometimes I don't write it down, I just keep it in my head . The Wound Nurse was asked why the skin inspection sheets documented that the skin was intact if Resident #50 had a wound on her right heel. The Wound Nurse stated, .there was nowhere to document. The Wound Nurse was asked if the physician had been notified on 5/28/18 when the wound was identified. The Wound Nurse stated, .no I just notified him today (6/26/18) . Interview with the Director of Nursing (DON) on 6/27/18 at 8:17 AM, in the Administrator's office, the DON was asked if it was acceptable that Resident #50's pressure ulcer was not assessed, or that the physician was not notified of the pressure wound from 5/28/18 until 6/26/18. The DON confirmed the Wound Nurse was aware of the pressure ulcer on Resident #50's right heel, and failed to notify the physician, and that the Wound Nurse initiated treatments without a physician's orders [REDACTED].I spoke with the CNA (Certified Nursing Assistant) last night, and she said there had been a dressing on it for quite some time, and (named Resident #50) said she (Wound Nurse) has been treating it for quite some time .I'm not sure why the weekly skin assessment didn't show it, because it was there when the skin assessment said it was intact .none of the rest of us were aware (of the pressure ulcer) . The DON was asked if any of the administrative staff ever made rounds with the wound nurse. The DON stated, No .we used to make rounds, and that just fell by the way . The DON confirmed it was not acceptable. There were inconsistencies of the description of the wound and when the physician was notifed by the Wound Nurse. The facility failed to perform an accurate skin assessment to identify a pressure ulcer, failed to notify the physician of the development of a new pressure ulcer for treatment orders and failed to accurately assess a reddened area before it deteriorated to a Deep Tissue Injury (DTI) resulted in actual Harm for Resident #50.

Based on facility policy review, medical record review, observation, and interview, the facility failed to implement effective fall prevention interventions for 1 of 8 (Resident #60) sampled residents. The failure of the facility to implement effective fall interventions resulted in actual Harm when Resident #60 fell after the malfunction of a chair alarm, and sustained a [MEDICAL CONDITION] which required surgical repair. The findings included: The facility's undated PERSONAL SAFETY ALARMS policy documented, .Personal safety alarms are used to alert that a resident who is at risk for falls .attempting to stand .get out of bed .or leave a desired area .All personal alarms and alert devices must be maintained in good working order at all times .The intent of personal safety alarms is immediate response to the sounding of an alarm to minimize the potential for a fall or injury .SPECIFIC PR[NAME]EDURE .Check the alarm to ensure it is in working order. If it is not working properly, check/replace the batteries. If still not working, lockout/tag out the device per facility policy and procure a working device immediately .Test the alarm to determine that the device chosen can be heard . Medical record review revealed Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment, and Resident #60 had 2 or more falls with no injury since admission and required assistance with transfers. The care plan dated 11/23/17 documented, .at risk for falls r/t (related to) impaired balance during transitions and poor safety awareness .Approaches .5/21/2018 .chair alarm added to alert staff of resident getting up unassisted . A FALL RISK EVALUATION (an assessment completed by nursing staff to assess the resident's potential to fall) revealed Resident #60 was at high risk for falls on 5/11/18. High risk for falls was a score of 10 or higher. A facility Resident Incident Report dated 5/21/18 documented, .Incident type .Fall .Immediate Actions Taken .apply bed/chair alarm . A physician's telephone order dated 5/21/18 documented, .Bed/chair alarm applied to alert staff of resident attempting to get up unassisted . A facility Resident Incident Report dated 5/24/18 at 7:30 AM, documented, .Incident type .Fall .RECOMMENDATIONS/INTERVENTIONS .Evaluation of foot wear, alarm replaced . A facility Teachable Moment dated 5/24/18 at 11:00 AM, documented, .Make sure .alarm working properly . A facility Resident Incident Report dated 5/24/18 at 11:30 AM, documented, .Incident type .Fall .Type of Injury .Fracture .Witness .(named Witness #1) . A physician's telephone order dated 5/24/18 at 12:00 PM, documented, .Send to (named hospital) ER (emergency room ) .d/t (due to) fall w/ (with) c/o (complaint of) pain to (R) (right) hip/leg, arm (and) head . A hospital radiology report dated 5/24/18 at 12:47 PM, documented, .Right intertrochanteric fracture . A physician's telephone order dated 5/24/18 at 2:30 PM, documented, .Transfer to (named hospital) for admission d/t (R) [MEDICAL CONDITION] . Observations in Resident #60's room on 6/25/18 at 10:17 AM, 11:47 AM, and 3:25 PM, on 6/26/18 at 2:26 PM and 4:49 PM, and on 6/27/18 at 8:02 AM, revealed Resident #60 lying in bed, was non-ambulatory, and required staff assistance for activities of daily living. Resident #60 fell on [DATE], and the new intervention was to use of bed/chair alarm. The resident fell on [DATE], at 7:30 AM, and a new intervention was to replace the chair alarm due to alarm malfunction. Resident #60 fell again 4 hours later on 5/24/18 at 11:30 AM. The chair alarm did not sound, and the fall resulted in a right [MEDICAL CONDITION] which required surgical repair for Resident #50. Telephone interview with Witness #1 (Not facility staff) on 6/27/18 at 8:55 AM, Witness #1 was asked if she remembered the incident when Resident #60 fell on [DATE]. Witness #1 stated, Yes .She (Resident #60) was in her wheelchair, and she got up and walked toward the nurses' desk. When she got to the corner, she started to stumble. She reached out to the med (medication) cart, the med cart rolled, and she went down to the ground . Witness #1 was asked if the alarm sounded when Resident #60 got up from her wheelchair. Witness #1 stated, I didn't hear anything. Telephone interview with Witness #2 (Not facility staff) on 6/27/18 at 9:02 AM, Witness #2 was asked if she remembered the incident when Resident #60 fell on [DATE]. Witness #2 stated, Yes .She (Resident #60) was walking toward the nurses' station, and she lost her balance, stumbled backward and tried to grab onto the med cart. The med cart wheels weren't locked, and she just kind of went down as it rolled. Witness #2 was asked if any kind of alarm sounded. Witness #2 stated, No. Interview with Registered Nurse (RN) #1 on 6/27/18 at 3:25 PM in the lobby, RN #1 was asked what happened when Resident #60 fell on [DATE] and fractured her hip. RN #1 stated, I wasn't on the hall when she fell , and by the time I got back there, she was already on the floor right in front of the nurses' station. RN #1 was asked if the chair alarm was sounding when he got to the hall. RN #1 stated, No. RN #1 was asked if the chair alarm was in place. RN #1 stated, Yes. The pad was in the chair and hooked up .I looked at the alarm, took it out of the chair, pressed on it and let go. Half the time the alarm would go off, and half the time it wouldn't .as far as we could tell the pad was faulty . Interview with the DON on 6/27/18 at 8:17 AM in the Administrator's office, the DON was asked if the facility has Patients at Risk meetings. The DON stated, .We have at risk meetings every Thursday. We go over falls, wounds and everything . Interview with the Director of Nursing (DON) on 6/27/18 at 9:50 AM, in the Administrator's office, the DON was asked who replaced the faulty chair alarm after Resident #60's fall on 5/24/18 at 7:30 AM. The DON stated, I think (named Central Supply Employee) checked it that morning, and it was working appropriately then . Interview with the Central Supply Employee on 6/27/18 at 9:21 AM, in the Administrator's office, the Central Supply Employee was asked how often she checked alarms. The Central Supply Employee stated, Daily .first thing in the mornings . The Central Supply Employee was asked if she had replaced the chair alarm for Resident #60 after the fall on 5/24/18 at 7:30 AM. The Central Supply Employee confirmed she did not replace it. Interview with the DON on 6/27/18 at 6:35 PM, in the Administrator's office, the DON was asked if she was aware that the chair alarm that was placed on 5/21/18 for Resident #60 was not working on 5/24/18. The DON stated, Isn't that the one in the recliner? The DON was asked if Resident #60 would have 3 alarms, one for the bed, one for the wheelchair, and one for the recliner. The DON stated, They usually can have one for the bed and one for the chair. The DON was asked if the staff would have used the same alarm for the recliner and the wheelchair. The DON stated, Yes . The DON was asked what staff should do if the alarm is not working. The DON stated, Go to the supply room and get them . The DON was asked what happens after hours for Central Supply needs. The DON stated, They can still go in and get them, and they leave her a note. Interview with the Central Supply Employee on 6/27/18 at 6:38 PM, in the Administrator's office, the Central Supply Employee was asked if the nursing staff had left her a note about a faulty chair alarm, or that they had taken one for Resident #60 that morning. The Central Supply Employee stated, No. The facility failed to implement effective fall interventions, which resulted in actual Harm to Resident #60.

Based on review of the Administrator's Job Description and the Director of Nursing's (DON) Job Description, and interview, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychological well-being of the residents, when they failed to recognize an ongoing concern with pressure ulcers and falls. The failure of the facility to be effectively and efficiently administered resulted in actual Harm to 1 of 2 (Residents #50) sampled residents with pressure ulcers. The failure of the facility to be effectively and efficiently administered resulted in actual Harm to 1 of 8 (Residents #60) sampled residents reviewed for falls. The administration failed to ensure skin assessments were ongoing and accurate, failed to ensure pressure ulcers were identified timely, failed to ensure the physician was notified timely of a pressure ulcer, and failed to ensure wound treatments were ordered by the physician prior to treatment initiation. Administration failed to ensure an effective fall prevention program, when an implemented fall intervention for use of a chair alarm was not functioning properly, and resulted in a fall with a [MEDICAL CONDITION], which required surgical repair. The findings included: Review of the Administrator's Job Description documented, .The primary purpose of your job position is to direct the day-to-day functions of the facility .Make routine inspections of the facility to assure that established policies and procedures are being implemented and followed .Assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies .Review and check competence of work force and make necessary adjustments/corrections as required or that may become necessary .Assist the Medical Director in the development and implementation of medical and nursing services and procedures and professional standards of practice .Ensure that the facility is maintained in a clean and safe manner for resident comfort and convenience by assuring that necessary equipment and supplies are maintained to perform such duties/services . Review of the DON's Job Description documented, .The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing Service Department .Develop a written plan of care .for each resident that identifies the problem and needs of the resident .Ensure that all personnel involved in providing care to the resident is aware of the resident's care plan .Ensure that nursing personnel refer to the resident's care plan prior to administering daily care to the resident .Review nurses' notes to determine that the care plan is being followed .Ensure that resident assessment information is transmitted on a timely basis .Review and revise care plans and assessments as necessary but at least quarterly . Interview with the DON on 6/27/18 at 7:51 AM, in the Administrator's office, the DON was asked how many falls had she investigated. The DON stated there had been 47 falls in the past 3 months. The DON was asked if the number of falls in the past 3 months was a concern. The DON stated, Yes ma ' am .47 is pretty low for 3 months . Interview with the Director of Nursing (DON) on 6/27/18 at 8:17 AM, in the Administrator's office, the DON was asked if it was acceptable that Resident #50's pressure ulcer was not assessed, or that the physician was not notified of the pressure wound from 5/28/18 until 6/26/18. The DON confirmed the Wound Nurse was aware of the pressure ulcer on Resident #50's right heel, and failed to notify the physician, and that the Wound Nurse initiated treatments without a physician's orders [REDACTED].I spoke with the CNA (Certified Nursing Assistant that was assigned to Resdient #50) last night, and she said there had been a dressing on it for quite some time, and (named Resident #50) said she (Wound Nurse) has been treating it for quite some time .I'm not sure why the weekly skin assessment didn't show it, because it was there when the skin assessment said it was intact .none of the rest of us were aware (of the pressure ulcer) . The DON was asked if any of the administrative staff ever made rounds with the wound nurse. The DON stated, No .We used to make rounds, and that just fell by the way . The DON confirmed it was not acceptable that Resident #50's pressure ulcer was not assessed or that the physician was not notified timely. Interview with the DON on 6/27/18 at 6:35 PM, in the Administrator's office, the DON was asked if she was aware the chair alarm that was placed as a fall intervention on 5/24/18 was not functioning when Resident #60 fell again on 5/24/18. The DON confirmed she was not aware. The DON was asked whether she expected previous fall interventions to be documented as effective or not in use on subsequent fall investigations. The DON stated, Yes, but I was not aware it was not working . Interview with the Administrator on 6/27/18 at 7:43 PM, in the Administrator's office, the Administrator was asked who was responsible to ensure the wound assessments were completed. The Administrator was unable to answer, and stated, That is something they discuss in their nursing meetings, not in our stand-up meetings. The Administrator was asked if the DON was responsible for ensuring the physician was notified of wounds, and that wound assessments were completed. The Administrator stated, Well, we both are, I guess. The Administrator was asked how she became informed of new wounds in the building. The Administrator stated, That would be clinical. They have their nurse meeting here, and sometimes I listen in if I'm not on a call .Also I attend their at-risk meetings held on Thursdays. The Administrator was asked if the physician had been notified of the missed wound assessments. The Administrator stated, I didn't talk to him. I don't know . The Administrator was asked who notified the Medical Director. The Administrator stated, I'm not sure. I'll have to ask (named the DON). Administration failed to ensure nurses provided and documented wound assessments for pressure ulcers, failed to revise the care plans to reflect the residents' current status for pressure ulcers, and failed to notify the physician of pressure ulcers, resulting in actual Harm to Resident #50. Refer to F580, F659, and F686. Administration failed to ensure an effective fall prevention program, which resulted in actual Harm to Resident #60 when an implemented fall intervention for use of a chair alarm was not functioning properly, and resulted in a fall with a [MEDICAL CONDITION], which required surgical repair. Refer to F689. Administration failed to ensure the Quality Assessment and Assurance (QAA) Committee identified the system failures related to pressure ulcers and falls and implemented corrective actions with ongoing monitoring. Refer to F867.

Based on facility policy review, medical record review, observation and interview, the facility's Quality Assessment and Assurance (QAA) Committee failed to have an effective, ongoing quality program that identified, developed, implemented and monitored appropriate plans of action for pressure ulcers and falls. The QAA Committee failure to ensure an effective pressure ulcer prevention and treatment system resulted in actual Harm for Resident #50 when she developed a pressure ulcer to the right heel on 5/28/18, and the facility's Wound Nurse failed to assess the wound, failed to notify the physician, failed to revise the care plan related to the pressure ulcer, and initiated wound treatments without a physician's orders [REDACTED].#60. The chair alarm intervention implemented for Resident #60 was not functioning properly, and resulted in a fall with a [MEDICAL CONDITION], which required surgical repair. The findings included: The facility's Quality Assurance and Performance Improvement (QAPI) Committee policy dated 7/16, documented, .The facility shall establish and maintain a Quality Assurance and Performance Improvement (QAPI) Committee that oversees the implementation of the QAPI Program .The Administrator shall delegate the necessary authority for the QAPI Committee to establish, maintain and oversee the QAPI program .The committee shall be a standing committee of the facility, and shall provide reports to the Administrator and governing board .The primary goals of the QAPI Committee are to .Establish, maintain and oversee facility systems and processes to support the delivery of quality of care and services .Help identify actual and potential negative outcomes relative to resident care and resolve them appropriately . The facility's Quality Assurance and Performance Improvement (QAPI) Program policy dated 4/14, documented, .The facility shall develop, implement, and maintain an ongoing, facility-wide Quality Assurance and Performance Improvement (QAPI) program that builds on the Quality Assessment and Assurance Program to actively pursue quality of care and quality of life goals .The primary purpose of the Quality Assurance and Performance Improvement Program is to establish data-driven, facility-wide processes that improve the quality of care, quality of life and clinical outcomes of our residents .The program is ongoing and comprehensive .Systems are in place to monitor care and services .Adverse events are tracked, monitored, and investigated as they occur .Actions plans are implemented to prevent recurrence or adverse events .Gathering and using QAPI data in an organized and meaningful way .Areas that may be appropriate to monitor and evaluate include .Clinical outcomes .pressure ulcers .falls .Taking systematic action targeted at the root causes of identified problems .This encompasses the utilization of corrective actions that provide significant and meaningful steps to improve processes and do not depend on staff to simply 'do the right thing . The QAA Committee failed to ensure the facility's pressure ulcer program was effective. The QAA committee failed to effectively track, trend and monitor the effectiveness of the pressure ulcer prevention program, failed to ensure care plans were revised to reflect residents current wound status, and failed to ensure the physician was notified timely of changes in resident status related to pressure ulcers. Refer to F580 F659, and F686 Interview with the DON on 6/27/18 at 7:51 AM, in the Administrator's office, the DON was asked who was ultimately responsible for ensuring nurses do the wound assessments. The DON stated, That would be me . The DON was asked what role the Administrator played in the clinical oversight of the facility. The DON stated, She is involved in all of our meetings . The DON was asked how the Medical Director was involved in management of wounds in the facility. The DON stated, We fax him, and we pick up the phone and call him. The DON was asked how the Medical Director was involved with fall management at the facility. The DON stated, I go over the trends and interventions at the QA (Quality Assurance) meeting. The DON confirmed the Medical Director reviewed and signed all incident reports. The DON was asked if she felt the facility's 47 falls documented for the past 3 months were a concern. The DON stated, Yes ma'am. I see every fall as a concern. But I also want to give all my patients as much as independence as possible .47 (falls) is pretty low for 3 months . Interview with the Director of Nursing (DON) on 6/27/18 at 8:17 AM, in the Administrator's office, the DON was asked if it was acceptable that Resident #50's pressure ulcer was not assessed, or that the physician was not notified of the pressure wound from 5/28/18 until 6/26/18. The DON confirmed the Wound Nurse was aware of the pressure ulcer on Resident #50's right heel, and failed to notify the physician, and that the Wound Nurse initiated treatments without a physician's orders [REDACTED].I spoke with the CNA (Certified Nursing Assistant) last night, and she said there had been a dressing on it for quite some time, and (named Resident #50) said she (Wound Nurse) has been treating it for quite some time .I'm not sure why the weekly skin assessment didn't show it, because it was there when the skin assessment said it was intact .none of the rest of us were aware (of the pressure ulcer) . The DON was asked if any of the administrative staff ever make rounds with the wound nurse. The DON stated, No .we used to make rounds, and that just fell by the way . The DON confirmed it was not acceptable. Interview with the Administrator on 6/27/18 at 7:43 PM, in the Administrator's office, the Administrator was asked who was responsible to ensure the wound assessments were completed. The Administrator was unable to answer, and stated, That is something they discuss in their nursing meetings, not in our stand-up meetings. The Administrator was asked if the DON was responsible for ensuring the physician was notified of wounds, and that wound assessments were completed. The Administrator stated, Well, we both are, I guess. The Administrator was asked how she became informed of new wounds in the building. The Administrator stated, That would be clinical. They have their nurse meeting here, and sometimes I listen in if I'm not on a call .Also I attend their at-risk meetings held on Thursdays. The Administrator was asked if the physician had been notified of the missed wound assessments. The Administrator stated, I didn't talk to him. I don't know . The Administrator was asked who notified the Medical Director. The Administrator stated, I'm not sure. I'll have to ask (named the DON). The QAA Committee failed to ensure the facility's fall prevention program was effective. The QAA committee failed to effectively track, trend and monitor the effectiveness of the fall prevention program. Refer to F689. The failure of the QAA to ensure an effective fall prevention program for a resident with severe cognitive abilities resulted in actual Harm to Resident #60 when she fell and sustained a [MEDICAL CONDITION] that required surgical repair.